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Development and Preliminary Validation of The'caring for Country'questionnaire: Measurement of an Indigenous Australian Health Determinant

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Development and Preliminary Validation of The'caring for Country'questionnaire: Measurement of an Indigenous Australian Health Determinant International Journal for Equity in Health BioMed Central Research Open Access Development and preliminary validation of the 'Caring for Country' questionnaire: measurement of an Indigenous Australian health determinant Christopher P Burgess*1, Helen L Berry2, Wendy Gunthorpe1 and Ross S Bailie1 Address: 1Menzies School of Health Research, Institute of Advanced Studies, Charles Darwin University, Darwin, NT, Australia and 2National Centre for Epidemiology & Population Health, The Australian National University, Canberra, ACT, Australia Email: Christopher P Burgess* - [email protected]; Helen L Berry - [email protected]; Wendy Gunthorpe - [email protected]; Ross S Bailie - [email protected] * Corresponding author Published: 18 December 2008 Received: 2 September 2008 Accepted: 18 December 2008 International Journal for Equity in Health 2008, 7:26 doi:10.1186/1475-9276-7-26 This article is available from: http://www.equityhealthj.com/content/7/1/26 © 2008 Burgess et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: 'Caring for Country' is defined as Indigenous participation in interrelated activities with the objective of promoting ecological and human health. Ecological services on Indigenous-owned lands are belatedly attracting some institutional investment. However, the health outcomes associated with Indigenous participation in 'caring for country' activities have never been investigated. The aims of this study were to pilot and validate a questionnaire measuring caring for country as an Indigenous health determinant and to relate it to an external reference, obesity. Methods: Purposively sampled participants were 301 Indigenous adults aged 15 to 54 years, recruited during a cross-sectional program of preventive health checks in a remote Australian community. Questionnaire validation was undertaken with psychometric tests of internal consistency, reliability, exploratory factor analysis and confirmatory one-factor congeneric modelling. Accurate item weightings were derived from the model and used to create a single weighted composite score for caring for country. Multiple linear regression modelling was used to test associations between the caring for country score and body mass index adjusting for socio-demographic factors and health behaviours. Results: The questionnaire demonstrated adequate internal consistency, test-retest validity and proxy- respondent validity. Exploratory factor analysis of the 'caring for country' items produced a single factor solution that was confirmed via one-factor congeneric modelling. A significant and substantial association between greater participation in caring for country activities and lower body mass index was demonstrated. Adjusting for socio-demographic factors and health behaviours, an inter-quartile range rise in caring for country scores was associated with 6.1 Kg and 5.3 Kg less body weight for non-pregnant women and men respectively. Conclusion: This study indicates preliminary support for the validity of the caring for country concept and a questionnaire designed to measure it. This study also highlights the importance of investigating Indigenous-asserted health promotion activities. Further studies in similar populations are merited to test the generalisability of this questionnaire and to explore associations with other important Indigenous health outcomes. Page 1 of 14 (page number not for citation purposes) International Journal for Equity in Health 2008, 7:26 http://www.equityhealthj.com/content/7/1/26 Background site for health [3]. This relationship is poorly understood, In Australia's Northern Territory (NT) more than 70% of unmeasured and receives only tacit recognition in Aus- the Indigenous population live on the 49% of the land- tralia's National Strategic Framework for Indigenous mass and 85% of the coastline that is Indigenous-owned health [16]. [1,2]. Colonial contact has largely displaced Indigenous peoples from their ancestral estates [3], relocating popula- Healthy Country Healthy People tions to remote area townships on Indigenous-owned Country is an Indigenous vernacular term encompassing lands [4]. This policy of centralisation, pursued in the last an interdependent relationship between Indigenous peo- decade with increasing vigour under the rubric of 'main- ples and their ancestral estates. streaming' [5,6], runs counter to evidence suggesting neg- ative health outcomes for these peoples [7,8]. In the "Country is multi-dimensional – it consists of people, ani- words of an Indigenous Australian: mals, plants, Dreamings; underground, earth, soils, min- erals and waters, air... People talk about country in the "Our identity as human beings remains tied to our land, same way that they would talk about a person: they speak to our cultural practices, our systems of authority and to country, sing to country, visit country, worry about social control, our intellectual traditions, our concepts of country, feel sorry for country, and long for country" [17]. spirituality, and to our systems of resource ownership and exchange. Destroy this relationship and you damage – Country is considered sentient [18], rewarding those who sometimes irrevocably – individual human beings and labour to maintain its mythic and physical integrity with their health" [9]. a bountiful harvest and bestowing physical, spiritual and social wellbeing [19]. Maintenance of health and well- Remote Indigenous townships are often described as cha- being requires hard work, sustained through mutual care otic and dysfunctional settings marked by social patholo- of kin, non-human affiliations and observance of ethical gies [10,11] and pervasive socio-economic disadvantages conduct described by the law or dreaming that is encoded [12]. Consistent with their extreme disadvantage, Indige- within country [17,19-21]. Failure to observe these obli- nous Australians' life expectancy is 17 years less than the gations may result in human sickness or ecological catas- Australian average with mortality rates for those aged 35– trophes [18,22]. 54 more than five times higher than the national average [10]. This also compares poorly with the life expectancy Urbanisation of remote Indigenous populations con- for Indigenous populations in New Zealand, Canada and strains opportunities to fulfil customary obligations to the United States [13]. For Indigenous Australians in the country. Although absence of landowners contributes to NT, a disproportionate burden of disease linked to inac- ecological degradation [23], contemporary forms of natu- tivity, malnutrition, and tobacco dependence underpins ral resource management have emerged to tackle environ- this wide health disparity [14]. Non-insulin dependent mental issues and maintain links with ancestral estates diabetes mellitus (NIDDM) and cardiovascular disease [24]. Indigenous ranger programs undertake a broad array account for 40% of excess Indigenous mortality and over of activities, including border protection, quarantine, and 21,800 preventable hospital admissions annually [10]. essential ecological services [3], that overlap with custom- Mainstream health promotion campaigns have been inef- ary obligations. fective in decreasing this burden of disease in such chal- lenging circumstances. Indigenous Australians living in homelands, where caring for country practices are common [25,26], appear to have Australia's peak health research body, the National Health better health outcomes compared to centralised popula- and Medical Research Council (NHMRC), recognises that tions [7,8,27,28]. Similarly, reinvigoration of a 'tradi- much previous health research "has not contributed in a tional lifestyle' delivers significant health improvements, significant or systematic way to improved health out- even for those with established NIDDM [29]. This is con- comes for Aboriginal and Torres Strait Islander popula- sistent with international examples of programs leverag- tions" [15]. Indigenous critics have demanded a shift in ing off extant cultural strengths to successfully combat research towards identifying 'what works', including (i) substance abuse and chronic diseases [30,31]. In the inter- improving the social determinants of health, (ii) identifi- national literature, however, there is a dearth of studies cation of cultural drivers of resilience and health gains and that explicitly engage, measure and validate Indigenous- (iii) the stipulation that solutions may arise from outside asserted health constructs, potentially overlooking signif- the health domain [15]. icant wellsprings of health promotion within Indigenous communities. There is a clear and urgent need for effective Indigenous health interventions. Indigenous Australians assert that The absence of any measure of Indigenous engagement in their relationship to ancestral land and sea is a prerequi- caring for country activities limits the potential to evaluate Page 2 of 14 (page number not for citation purposes) International Journal for Equity in Health 2008, 7:26 http://www.equityhealthj.com/content/7/1/26 or inform policy decisions based on associations with Three participants did not complete the caring for country purported superior health outcomes [32]. questionnaire. Ten could not have weight
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